Prof Rupert Leong,€¦ · Retroscope through working channel reverse view uses up channel Third Eye Panoramic Cap clip on, 3 cameras 330 degrees intubating ileum, >25 use Full spectrum

10:30-10:50 25 Sept 2017 Monday A-PSDE / WEO Colorectal Cancer Screening Committee (CRCSC) Meeting Room S228 (2/F)

IBDSydney

Prof Rupert Leong, Director of Endoscopy, Head of IBD Professor of Medicine UNSW, University of Sydney, Concord Hospital Australia

Prof Rupert Leong

Advisory board: AbbVie, Aspen, Ferring, Hospira, Janssen, Pfizer, Takeda

Research: Shire, Endochoice, Janssen

Prof Rupert Leong

n=88,902: 22 year

1,815 incident CRC, 474 deaths

▪ polypectomy: HR CRC 0.57 (95% CI: 0.45-0.72)

▪ HR CRC death 0.32 (0.24-0.45)

Colonoscopy reduces CRC and CRC Mortality

n=136 gastroenterologists ADR: 7.4-52.5%

Risk of interval CRC

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0.52

1% increase in ADR decrease 3%

risk CRC HR: 0.77 (0.96-0.98)

Corley NEJM 2014

improve adenoma detection: 1. optimize patient selection

2. improve quality

3. colonoscopy technique ▪ i. optimize bowel preparation

▪ ii. withdrawal time >6 minutes

▪ iii. “look again”: re-insertion, retroflex, work folds

▪ iv. technology: Endocuff, Endoring, panoramic

Corte, Leong. J Gastroenterol Hepatol 2015

increase ADR decreases risk of CRC

Prof Rupert Leong

improve adenoma detection

flat

behind folds

blind spots

fold-flattening panoramic endoscopy

Aranda-Hernández World J Gastro 2016

Endocuff

EndoRing G-Eye Balloon

Transparent Cap

Fold flattening devices

Third Eye Retroscope

Aranda-Hernández World J Gastro 2016

FUSE

Third Eye Panoramic

Panoramic endoscopy

Prof Rupert Leong

cap:

polyps RR 1.08 (1.0-1.17)

caecal intubation time -0.64min

Ng Am J Gastroenterol 2012

Prof Rupert Leong

n=1,063, n=530 Endocuff, n=533 CC surveillance, symptoms, screen, FIT ADR 52% CC vs 52% Endocuff

flat adenomas 0.27/ individual vs 0.16 (P<0.01); small adenomas 0.91 vs 0.74 (P=.03)

22 failed sigmoid intubation van Doorn Gut 2015

Prof Rupert Leong

reusable balloon & inflation system

0.1mm diameter

straighten folds and flexures n=126 tandem colonoscopy

balloon colonoscopy missed 7.5% vs 45% colonoscopy (P=0.0002)

detection 81% additional adenomas Halpem Endosc 2015

Prof Rupert Leong

retroflexed 2nd camera uses up channel

Prof Rupert Leong

n=29: +4 polyps; 11.8% increased yield n=249: +16% adenomas n=298: +11% adenomas n=349: +23% adenomas

Triadafilopoulos Endosc 2008 DeMarco Gastrointest Endosc 2010

Waye Gastrointest Endosc 2010 Leuflkens Gastrointest Endosc 2011

Prof Rupert Leong

CMOS, LED 300 degree viewing frees channel ICV intubation challenge lens wash

reusable version

Rubin World J Gastro 2015

Prof Rupert Leong

n=33, screening, surveillance, diagnostic ADR 44% 100% caecal intubation; intubation time 8min

Rubin World J Gastro 2015

170° Field of View

330°

168cm length 12.8mm diameter high res full tip mobility

3.8mm channel

Prof Rupert Leong

19

Prof Rupert Leong

20

Prof Rupert Leong

tandem colonoscopy study 18-70yo; screening, assessment, follow up conventional colonoscopy first or FUSE first

Conventional Colonoscopy

n=88

FUSE

n=97

P

Adenoma miss rate 20/ 49 (41%) 5 / 67 (7%) <0.0001

Gralnek Lancet Oncol 2015

Standard

colonoscopy (n=88)

FUSE

(n=97)

Missed adenoma by 1st procedure 20 / 49 (41%) 5 / 67 (7%)

Morphology: total 20 5

Pedunculated 2 0

Sessile 18 5

Size : ≥10mm 1 0

6-9mm 5 0

<5mm 14 5

Subtype TA (18), TVA (1)

and villous (1) Tubular (5)

Location

Right 14 2

Left 6 3

Finding require change in surveillance 9.1% (8/88) 0% (0/97)

Gralnek Lancet Oncol 2015

Conventional colonoscopy misses

small, proximal colonic polyps

Cesare Gut 2016

screening +ve FIT; 7 Italian centres

high ADR (40%), first gen, learning curve

1 adenoma identified = ADR already met

Conventional Colonoscopy

n=330

FUSE n=328

ADR n (%) 150/330 (45.5) 143/328 (43.6)

Advanced ADR n (%) 23.0% 64/328 (19.5)

Prof Rupert Leong

Facciorusso J Gastro Hepatol 2017

Adenoma Miss Rate RR: 0.35 (95%CI: 0.25-0.48)

Prof Rupert Leong

Adenoma Detection Rate: 1.05 (0.94-1.17)

Facciorusso J Gastro Hepatol 2017

Prof Rupert Leong

Total colonoscopy time

Facciorusso J Gastro Hepatol 2017

Prof Rupert Leong

Adenoma Detection

RR (95% CI)

Adenoma Miss Rate

RR (95% CI)

Right-sided 1.10 (0.87-1.39) 0.27 (0.10-0.73)

Left-sided 0.92 (0.69-1.21) 0.33 (0.14-0.77)

Size ≤5mm 1.09 (0.99-1.24) 0.26 (0.15-0.48)

Size >5mm 1.01 (0.94-1.43) 0.38 (0.09-1.60)

Flat / sessile 1.32 (0.35-4.99) 0.26 (0.13-0.51)

Pedunculated 1.04 (0.83-1.30) 0.15 (0.01-3.00)

Facciorusso J Gastro Hepatol 2017

FUSE: small adenomas; R & L colons

ADR same

Gastro-esophageal Junction

Flat Sessile Polyp

Off High

Off High

Adaptive Matrix Imaging Off On

Off On

Pending FDA clearance

Not for sale in the US

• Always on capability

• Maintains natural colors

• Smart enhancement

• Designed to reduce distraction

Markov model

cost-effectiveness of FUSE

+16% increased cancer prevention: 58% to 74%

gain of 9 days per person

cost of cancer care decreased $90M to $57M

savings $145 per person

Hassan Digest Endosc 2015

Prof Rupert Leong

232 degrees

n=319: ADR 1.1 vs 1% (P=0.43)

Prof Rupert Leong

Rex 1997 Gastro n=183

vs. TFV 24% 2nd Pass 31%

vs. TFV 41%

Gralnek 2014 Lancet Oncol n=185

FUSE 69%

Adenoma Miss Rates

Additional Adenomas Detected by 2nd Procedure

Tandem Studies

TFV 31% Third Eye 46% vs. Siersema 2012 World J Gastro n=349

Rex 2011 GI Endosc n=1,000

vs. 2nd Pass +12% on retroflexion

Technology Improvement Negatives

Cap flatten folds cheap -

Third Eye Retroscope

through working channel

reverse view uses up channel

Third Eye Panoramic Cap

clip on, 3 cameras

330 degrees intubating ileum, >25 use

Full spectrum endoscopy

3 cameras incorporated, LUMOS

330 degrees initial capital (minimal training)

Endocuff flatten folds cheap intubating ileum

EndoRing flatten folds cheap intubating ileum

Prof Rupert Leong

what is the best measure of quality? who will benefit most from technologies?

high ADRs? low ADRs?

incremental gain?

slow withdrawal, high quality bowel prep?

negatives?

learning curve, difficult intubation, use channel

cost benefit?

cheap cap vs FUSE

Prof Rupert Leong

endoscopic technology

decreases adenoma miss rate

▪ improve CRC screening efficacy; reduces interval CRC

FUSE:

decreased adenoma miss rates; ADR not increased

other techniques: less established

Prof Rupert Leong

Prof Rupert Leong

Where is the panda?

Prof Rupert Leong

Gralnek Leong Cesare

Population mixed IBD surveillance +ve FIT

Endpoint adenoma miss rate adenoma miss rate adenoma detection rate

Adenoma Miss Rate

7% FUSE vs 41% CC

25% FUSE vs 71% CC

P= 0.0001

Adenoma Detection Rate

73% FUSE vs 27% 43.6% FUSE vs 45.5% CC

P= 0.007